STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. . Case No. 2005009684 CHARLES AND CATHERINE ARNOLD, d/b/a ARNOLD’S ANGELS, O lo . OloT 5 Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against CHARLES AND CATHERINE ARNOLD, d/b/a ARNOLD’S ANGELS (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2005), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate an assisted living facility or, in the alternative, to impose an administrative fine in the sum of forty-seven thousand dollars ($47,000.00) based upon nine (9) cited State Class II deficiencies and two (2) cited repeat State Class III deficiencies pursuant to §400.419(2)(b) and (c) Fla. Stat. (2005). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. (2005). Ww Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapter 400, Part IIL, Florida Statutes, and; Chapter 58A- 5 Fla. Admin. Code, respectively. . 4. Respondent operates a 6-bed assisted living facility located at 5634 Bradshaw Street, Jacksonville, Florida 32277, and is licensed as an assisted living facility, license number 10365. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) and the remainder of this Complaint as if fully recited herein. 7. That the Agency may revoke any license issued under Part III of the Florida Statutes for the citation of one (1) or more cited class I deficiencies, three (3) or more cited class II deficiencies, or five (5) or more cited class II deficiencies that have been cited on a single survey and have not been corrected within the specified time period. Section 400.414(1)(e) Fla. Stat. (2005). In addition, the Agency may revoke any license issued for failure of the applicant, the licensee during relicensure, or a licensee that holds a provisional license to meet the minimum license requirements of this part, or related rules, at the time of license application or renewal. Section 400.414(1)(i) Fla. Stat. (2005). 8.- That the Respondent holds a conditional license. 9. That the Respondent has been cited with nine (9) class II deficiencies and two (2) Class III repeated deficiencies on an Agency survey of October 8, 2005. 10. ‘That based thereon, the Agency seeks the revocation of the Respondent’s licensure as its primary relief herein, seeking the assessment of fines solely in the alternative. we li. That should the Respondent admit the facts herein by action or inaction, the Petitioner shall enter an Order revoking the Respondent’s licensure in lieu of other relief sought herein. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate an assisted living facility in the State of Florida, pursuant to § 400.414(1)(e) and (i), Fla. Stat. (2005). COUNT II 12. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 13. That any license granted by the Agency must state, inter alia, the maximum resident capacity of the facility. Section 400.407(3), Fla, Stat. (2005). “Capacity” means the number of residents for which a facility has been licensed to provide care. R. 58A-5.0131(7) Fla. Admin. Code. A facility may not exceed its licensed capacity... R. 58A-5.0181(2)(g) Fla. Admin. Code. 14. That on January 10, 2005, the Agency conducted a complaint investigation of the Respondent. 15, That based upon observation, the review of records, and staff interview, the Respondent facility exceeded its licensed capacity of residents in violation of law. 16. That the Respondent facility has been licensed by the Petitioner for a capacity of six (6) residents. 17. That the Petitioner’s representative reviewed the Respondent’s facility records on January 10, 2005. 18. That observations made in the facility and record review on January 10, 2005 reflected that eight (8) residents were actively residing in the Respondent facility. 19, That the Petitioner’s representative interviewed the Respondent’s staff on January 10, 2005, who confirmed that eight (8) individuals were residing in the Respondent facility at that time. 20. ‘That exceeding the licensed capacity of the facility places all residents at risk for unmet care needs, deprives the resident’s of adequate living areas, and places all residents in an overcrowded living condition. 21. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a State Class III deficiency. 22. That the Agency provided the Respondent with a mandatory correction date of February 10, 2005. 23. That during a re-visit survey conducted February 15, 2005 the Agency determined that the Respondent had corrected the deficiency. 24. That on October 8, 2005, the Agency conducted an Appraisal Survey of the Respondent. 25. That based upon the review of facility records and observations on October 8, 2005, the facility exceeded the licensed capacity of its current license 26. ‘That the Petitioner’s representative reviewed the Respondent’s facility records on October 8, 2005. 27. ‘That a review of facility records revealed that the Respondent facility had documented only four (4) individuals in residence on October 8, 2005. 28. That based on observations during a tour of the Respondent facility there were eight (8) individuals residing at the facility during the survey. 29. That the Petitioner’s representative interviewed resident number four (4) on October 8, 2005 who revealed that a ninth (9") individual was in residence at the Respondent’s facility, said individual sharing a room with resident number two (2). The subject individual was not at the Respondent facility at the time of the resident’s interview. 30. That the Petitioner’s representative observed the resident bed in which resident number (4) alleged a ninth resident slept at the facility, said bed clearly reflecting from is rumpled and disheveled status that it had in fact been in use the night before and that an additional resident resided therein. 31. That exceeding the licensed capacity of the facility places all residents at risk for unmet care needs, deprives the resident’s of adequate living areas, and places all residents in an overcrowded living condition. 32. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a repeat State Class IIL deficiency. 33. That the Agency provided the Respondent with a mandatory correction date of November 8, 2005. 34. That the same constitutes a repeat offense as defined in Florida Statute 400.419(2)(c). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2005). COUNT I 35, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 36. That pursuant to Florida law, any person who fraudulently alters, defaces, or falsifies any medical or other record of an assisted living facility, or causes or procures any such offense to be committed, commits a misdemeanor of the second degree. Section 400.449 Fla. Stat. (2005). 37. That on October 8, 2005, the Agency conducted an Appraisal Survey of Respondent. 38. That based upon a review of the Respondent’s admission/discharge log, a review of the Respondent’s resident records, and an interview with the administrator on October 8, 2005, the facility falsified or fraudulently altered the admission and discharge log, and a health assessment of one resident. 39. That a review of the Respondent’s admission/discharge log on the day of the survey reflected that only four (4) residents were currently residing at the facility. 40. That observation during the tour of the facility and interview with residents revealed nine (9) individuals were in residence at the facility. 41. That the facility is licensed for six residents. 42. That three (3) of the nine (9) current residents had been annotated on the Respondent’s admission/discharge log as having previously discharged from the facility. 43. That two (2) of the residents were noted as discharged on a previous survey on August 10, 2005. 44. That the Petitioner’s representative interviewed the residents of the facility on October 8, 2005, who confirmed that the three (3) residents who are indicated in Respondent’s records as having been discharged had continuously resided at the Respondent facility and that staff had kept the residents hidden from regulators. 45. That falsifying the admission/discharge records puts residents at risk for unmet care needs and is a second degree misdemeanor. 46. That the petitioner’s representative reviewed the Respondent’s records regarding resident number four (4). 47, That the health assessment of resident number four (4), dated August 1, 2005, appears to have been altered as follows: a. That the diagnosis of the resident on a health assessment dated March 9, 2005, is Diabetes Mellitus, Epilepsy, Schizophrenic disorder, and a history of bipolar disorder with schizophrenia relapse; b. That on the health assessment dated August 1, 2005, the diagnosis states the resident has Diabetes Mellitus, and Epilepsy; c. That there is no mention of any mental health diagnoses on the August 1, 2005 health assessment; d. That the remainder of the two health assessments are similar, but not, identical; e. That the health assessments are purported to be from a Dr. Atul Sharad, but the signatures although similar appear to be different; f. That a former employee of the Respondent has asserted that the resident’s . assessment had been altered. 48. That four (4) residents observed at the facility and one (1) resident not observed at the facility at the time of the survey had no records of any kind. 49. That observations revealed that medications were maintained by the Respondent for these residents and staff of the Respondent administered medications to these residents, but no requisite record of the assistance is available. 50. That the Petitioner’s representative interviewed Respondent’s staff who stated that four residents were residents of the facility, but could or would not explain the other residents or what services were being provided to these residents. 51. That based on the above information, the Agency concluded that resident care and services is suspect and that information received from staff was false. Falsifying records puts residents at risk for unmet care needs and is a second degree misdemeanor. 52. That this behavior and lack of information regarding all the residents’ care leave the residents at risk for not receiving care or receiving inadequate care, 53. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 54. That the Agency provided Respondent with a mandatory correction date of October 11, 2005. 55. That the same constitutes grounds for a Class II deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(1)(b), Fla. Stat. (2005). COUNT IV 56. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 57. That pursuant to Florida law, it is the intent of the legislature that rules published and enforced include criteria by which a reasonable and consistent quality of resident care and quality of life may be ensured including facility and staff records. Section 400.441(1)(e) Fla. Stat. (2005). In accord therewith, the facility shall maintain written records, in a form, place, and system ordinarily employed in good business practice and accessible to department and agency staff, including an up-to-date admission and discharge log listing the names of all residents and, inter alia, each resident’s date of admission, date of discharge and reason therefore. R. S8A- 5.024(1)(b) Fla. Admin. Code. 58. That on January 10, 2005, the Agency conducted a complaint investigation of the Respondent. 59. That based upon a review of the Respondent’s admission/discharge log and observation, the Respondent facility failed to ensure an up to date admission and discharge log was maintained in violation of law. 60. That the Petitioner’s representative reviewed the Respondent’s facility records on January 10, 2005. 61. That review of the facility admission and discharge log on January 10, 2005 revealed eight (8) residents currently living in the facility. 62. That interview with staff revealed that there were indeed eight residents living in the facility. 63. That further examination of the log revealed that the newest admitted resident had not been entered into the log yet, and one resident had never been admitted or discharged in the log. 64, That the Respondent’s admission/discharge log was neither accurate nor up-to-date regarding the current residents of the Respondent facility in violation of law. 65. That the failure to maintain an accurate log puts residents at risk for unmet care needs and potential hazardous conditions due to erroneous information regarding the actual number of residents in the facility. 66. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a State Class III deficiency. 67. That the Agency provided the Respondent with a mandatory correction date of February 10, 2005. 68. That during a re-visit survey conducted February 15, 2005 the Agency determined that the Respondent had corrected the deficiency. 69. That on May 25, 2005, the Agency conducted a biennial licensure survey of the Respondent. 70. That based upon the review of records and interview the Respondent facility failed to maintain an up-to-date admission and discharge log. 71. That the Petitioner’s representative reviewed the Respondent’s admission/discharge log on May 25, 2005. 72. That the Respondent’s admission and discharge log revealed that five (5) individuals as current residents of the respondent facility. 73. That the Petitioner’s representative observed a sixth (6) resident whose name and other requisite information was not recorded in the respondent’s admission and discharge log though the individual had been in residence for a period in excess of thirty days. 74. That Petitioner’s representative interviewed the respondent’s administrator who, upon review of the log with the caregiver on duty, recognized and confirmed that an omission had occurred. 75. That the failure to maintain an accurate log puts residents at risk for unmet care needs and potential hazardous conditions due to erroneous information regarding the actual number of residents in the facility. 76. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a State Class HI deficiency. 77. That the Agency provided the Respondent with a mandatory correction date of June 25, 2005. 78. That during a re-visit survey conducted July 7, 2005 the Agency determined that the Respondent had corrected the deficiency. 79. That on October 8, 2005, the Agency conducted an Appraisal Survey of the Respondent. 80. That based upon the review of records, interview, and observation, the respondent facility failed to maintain an up-to-date admission and discharge log in violation of law. 81. That the Petitioner’s representative reviewed the Respondent’s facility records on October 8, 2005. 82. That a review of the facility's admission and discharge log revealed that four (4) residents were listed as current residents of the facility. 83. That the Petitioner’s representative interviewed Respondent’s aide on October 8, 2005, who indicated that the facility had only four (4) residents. 84. That based on observations during a tour of the Respondent facility there were eight (8) individuals residing at the facility during the survey. 85. That the Petitioner’s representative interviewed resident number four (4) on October 8, 2005 who revealed that a ninth (9") individual was in residence at the Respondent’s facility, said individual sharing a room with resident number two (2). The subject individual was not at the Respondent facility at the time of the resident’s interview. 86. That the Petitioner’s representative observed the resident bed in which resident number (4) alleged a ninth resident slept at the facility, said bed clearly reflecting from is rumpled and disheveled status that it had in fact been in use the night before and that an additional resident resided therein. 87. That the failure to maintain an accurate log puts residents at risk for unmet care needs and potential hazardous conditions due to erroneous information regarding the actual number of residents in the facility. 88. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a repeat State Class IT] deficiency. 89. That the Agency provided the Respondent with a mandatory correction date of November 8, 2005. 90. That the same constitutes a multiple repeat offense as defined in Florida Statute 400.419(2)(c). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2005). COUNT V 91. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 92. That pursuant to Florida law, the facility shall maintain written records, in a form, place, and system ordinarily employed in good business practice and accessible to department and agency staff, including resident records including, inter alia, demographic data, medical examination, health care orders, a written resident records etc., which shall be maintained for two years following discharge. R. 58A-5.024(3) Fla. Admin. Code. 93. That on January 10, 2005, the Agency conducted a complaint investigation of the Respondent. 94. That based upon the review of the Respondent’s resident records and staff interview the Respondent failed to maintain and or failed to produce written records with regard to sampled and unsampled residents residing in the facility and sampled and unsampled residents who had been discharged. 95. That the Petitioner’s representative reviewed the Respondent’s facility records on January 10, 2005 regarding resident number one (1) and found that the record was incomplete and that the resident was not listed at any time on the Respondent’s admission/discharge log. 96. That the Petitioner’s representative interviewed the Respondent’s staff and a family member of resident number one who verified that the resident resided in the facility from March 2004 through January 3, 2005. 97. That the Respondent maintained and or failed to produce any records on January 10, 2005 for four (4) residents residing in the Respondent’s facility on that date. 98. That the Petitioner’s representative reviewed Respondent’s records regarding resident’s who had been discharged and discovered one record, for resident number five (5) was available while records for the remaining four (4) discharged residents were not maintained or produced. 99. That such records contain critical medical, demographic, and treatment records which could be necessary for the ongoing health and medical needs of the residents. The failure to maintain resident records threatens residents’ health by not properly documenting care and services required for each resident. 100. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 101. That the Agency provided the Respondent with a mandatory correction date of February 10, 2005. 102. That during a re-visit survey conducted February 15, 2005 the Agency determined that the Respondent had corrected the deficiency. 103. That on October 8, 2005, the Agency conducted an Appraisal Survey of the Respondent. 104. That based upon the review of resident records, observations and interviews with staff and a resident, the facility failed to maintain resident records on the premises as required by law. 105. That the Petitioner’s representative reviewed the Respondent’s facility records on October 8, 2005. 106. That a review of all resident records revealed that only four (4) of nine (9) resident records were available to the surveyors. 107. That the Petitioner’s representative observed during a tour of the Respondent facility that there were eight (8) residents at the facility. 108. That the Petitioner’s representative interviewed resident number four (4) who indicated that a ninth (9"") resident was staying at the facility, but was out of the facility at the time of the survey. 109. That the Respondent failed to produce for review any resident records for five (5) residents at the facility. Inclusive of required records not available for the five (5) residents are resident health assessments, Medication Observation Records, demographic information, or notes of any description regarding the residents and the care offered or received. 4 110. That the Petitioner’s representative observed the eight residents at the facility during the survey of October 8, 2005 and noted that seven (7) residents were being provided care and being assisted with medications. 111. That these medications were administered without requisite supporting documentation including, but not limited to, medical orders, prescriptions, and administration records. 112. That this practice by the facility places these residents at risk for not receiving appropriate care due to the lack of information from a physician to determine the appropriate care required for the residents or records reflecting compliance with physician’s orders and reactions thereto. 113. That such records contain critical medical, demographic, and treatment records which could be necessary for the ongoing health and medical needs of the residents. The failure to maintain resident records threatens residents' health by not properly documenting care and services required for each resident. 114. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 115. That the Agency provided the Respondent with a mandatory correction date of October 11, 2005. 116. That the same constitutes a repeat offense and as such, in part, justifies the imposition of an enhanced fine. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2005). COUNT VI 117. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 118. That pursuant to Florida law, an individual must meet minimum criteria for residence in an assisted living facility including, inter alia, the ability to perform the activities of daily living with assistance or supervision, if necessary, the ability to transfer, with assistance if necessary, including the assistance of more than one person, and not be bedridden. R. S8A-5.0181(1) Fla. Admin. Code. “Assistance with transfer” means providing verbal and physical cuing or physical assistance or both while the resident moves between bed and a standing position or between bed and chair or wheelchair. R. 58A-5.0131(5) Fla. Admin. Code. “Bedridden” means confined to bed because of inability to ambulate or transfer to a wheelchair even with assistance, or to sit safely in a chair or wheelchair without personal assistance or mechanical restraint. R. 58A- 5.0131(6) Fla. Admin. Code. Ifa resident no longer meets the criteria for continued residency, or the facility is unable to meet the resident’s needs, the resident shall be discharged in accordance with law. R. 58A-5.0181(5) Fla. Admin. Code. 119. That on October 8, 2005, the Agency conducted an Appraisal Survey of Respondent. 120. That based upon observations, interviews with the administrator and staff, and a review of resident records, the Respondent retained a resident who no longer meets the criteria for continued residency in violation of law. 121. That the Petitioner’s representative, while touring the Respondent facility on October 8, 2005, observed an awake resident number one (1) in the resident’s bed. Resident one (1) had been identified by the Agency as inappropriate for continued residence in an assisted living facility during the Agency’s survey of August 10, 2005. 122, That the following was observed by the Petitioner’s representative and noted from conversation with Respondent’s staff: a. That at 10:00 am, the resident had a bowel movement and the aide changed her diaper and cleaned her; That a diaper is used at all times and only after the resident has voided, the staff will assist with a change of the diaper; That the resident is unable to communicate toileting needs and the staff cannot communicate to the resident the need to toilet prior to voiding without assistance; That the staff attempted to transfer the resident from the wheelchair to the bed; That to accomplish this, the resident must be lifted with total care by staff, from the wheelchair to the bed or the reverse; That the resident is unable to pivot on legs or assist with arms; That the resident’s arms and legs are atrophying from lack of use and when in bed, the resident tends to lie in only a fetal position; That at 10:45 a.m. the resident was presented with breakfast and given a spoon; That the resident was left alone for about thirty minutes during which time she ate approximately ten percent (10%) of her food; That the resident slowly started to collapse in the wheelchair and slide to the floor; . That an aide noted this and pulled her to a sitting position where the aide hand fed approximately ten percent (10%) of the resident’s food to the resident; That the resident was then placed back in bed. 123. That the Petitioner’s representative reviewed the most recent health assessment of resident number one (1) which asserts that the resident is able to assist in bathing, dressing, toileting and transferring. 124. That the current condition of this resident is not reflected in the health assessment. 125. That the Petitioner’s representative interviewed the Respondent’s administrator and aide who noted that the resident has lost weight and is receiving supplemental meals without a positive response. 126. That the Respondent’s staff indicated that the resident is unable to assist in any of the activities of daily living except for eating. 127. That the facility has not weighed resident number one (1) due to the lack of equipment necessary to weigh this resident. 128. That resident number one (1), based upon observation dating back to May of 2005, is losing weight, part of which is due to her condition and part due to the staff not being able to provide the appropriate care. 129. That this resident is at risk of continuing to lose weight and is at risk for additional medical problems. 130. That the Respondent’s records contained no indicia that the Respondent had initiated the discharge of the resident. 131. That resident number one (1) does not meet the minimum requirements for residence in an assisted living facility as the resident is unable to perform activities of daily living or transfer with assistance and is bedridden. In addition, the Respondent facility is unable to meet the needs of the resident as evidenced by its failure to maintain weight records or address the resident’s continuing health issues including weight loss. That the continued retention of this resident threatens the resident's health and safety due to the inability of staff to meet ongoing needs. 132. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 133. That the Agency provided Respondent with a mandatory correction date of October 11, 2005. 134. That the same constitutes grounds for a Class II deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(1)(b), Fla. Stat. (2005). COUNT VII 135. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 136. That pursuant to Florida law, facilities shall maintain minimum staff hours per week based upon the number of residents, to wit: 0-5 residents require one hundred sixty eight (168) staff hours per week and 6-15 residents require two hundred twelve (212) staff hours per week. R. 58A-5.019(4)(a) Fla. Admin. Code. 137. That on October 8, 2005, the Agency conducted an Appraisal Survey of Respondent. 138. That based upon a review of the employee work schedule and interviews with employees on October 8, 2005, it was determined that the facility did not meet the minimum staff hours as required in violation of law. 139. That the Petitioner’s representative reviewed the respondent’s staffing schedule which reflected the presence of one employee working eight hours per day, three shifts per day and seven days a week. 140. That this is a total of one hundred sixty eight (168) staff hours. 141. That the petitioner’s representative interviewed the three staff members present who indicated the following: a. That each person present that day normally works alone; b. That the third shift employee stayed at the facility during the survey and stated that he normally goes home as soon as the first shift arrives; c. That he decided to stay based on the surveyors’ arrival and the request of the first shift aide; d. That there was one employee who was at the facility to be trained by the first shift aide and she was there for training; e. That the first shift aide, who also stated that she was in charge due to the absence of the administrator, confirmed the status of the other employees and stated that only one person worked each of three shifts. 142. That the Petitioner’s representative observed eight (8) individuals resident in the facility. 143. That the Petitioner’s representative interviewed resident number four (4) who indicated that a ninth resident had left the facility just prior to 8:30 a.m. and that he shared a room with resident number two (2). 144, That with more than six residents at the facility the staffing should be a minimum of two hundred twelve (212) hours. 145. That the lack of staffing contributes to the inability of staffto meet the needs of the residents and the failure to meet minimum staffing hours threatens the health and safety of residents due to the inability to meet the scheduled and unscheduled needs of the residents. 20 146. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 147. That the Agency provided Respondent with a mandatory correction date of October 11, 2005. 148. That the same constitutes grounds for a Class II deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(1)(b), Fla. Stat. (2005). COUNT VII 149. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 150. That pursuant to Florida law, notwithstanding minimum staffing requirements of rule, all facilities shall have enough qualified staff to provide resident supervision and to provide or arrange for resident services in accordance with the resident’s scheduled and unscheduled service needs, resident contracts, and resident care standards. R. 58A-5.019(4)(b) Fla. Admin. Code. 151. That on October 8, 2005, the Agency conducted an Appraisal Survey of Respondent. 152. That based upon the review of resident records and observation of residents at the facility, the Respondent facility failed to have enough qualified staff to provide for resident supervision, or to provide for the scheduled and unscheduled needs of the residents. 153. That the Petitioner’s representative observed that of the nine (9) residents at the facility, two (2) residents required total assistance or care to meet their needs as evidenced as follows: a. Resident number one (1) is unable to assist in any of her activities of daily living and requires total care for all of her needs; b. Resident number three (3) requires total assistance in all of her activities of daily living except for eating; c. That resident number three (3) was not out of bed until intervention by a surveyor at approximately 10:30 a.m; d. That resident number three (3) was then assisted in transferring to a wheelchair and brought out to have breakfast served; e. That no assistance with bathing, brushing teeth, toileting or other assistance was offered to resident number three (3); f. That morming medications for all the residents were not provided until after 10:00 a.m., and this was only accomplished because additional, unscheduled staff members were present at the facility as a result of training and request due to the Petitioner’s arrival for its survey of the Respondent; g. That this additional staff were able to lend assistance with the needs of residents three (3) and four (4); h. That without this assistance, one or more of the residents would not have received the appropriate assistance as dictated by their health assessments. 154. That the nine residents at the Respondent facility would need assistance in excess of the minimum staffing due to the level of required care and the number of residents currently residing at the facility. 155. That any unscheduled needs for any of these residents could not be handled by the minimum staffing requirements, due to the lack of qualified staff, which places all of the residents at risk for complications to their current medical conditions in violation of law. The failure to have sufficient staff on duty threatens the residents' health and safety due to the staff's inability to meet the resident’s immediate needs and therefore an inability to meet unscheduled needs. 156. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class IJ deficiency. 157. That the Agency provided Respondent with a mandatory correction date of October 11, 2005. 158. That the same constitutes grounds for a Class II deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(1)(b), Fla. Stat. (2005). COUNT IX 159. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 160. That pursuant to Florida law, for residents who receive assistance with self- administration or medication administration, the facility shall maintain a daily up-to-date, medication observation record (MOR) for each resident. A MOR must include, inter alia, the name of each medication prescribed, its strength, and directions for use; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The MOR must be immediately updated each time the medication is offered or administered. R. 58A-5.0185(5)(b) Fla. Admin. Code. 161. That the Petitioner’s representative reviewed the Respondent’s facility records on January 10, 2005. 162. That based upon review of the Respondent’s records and medications on January 10, 2005 it was determined that the facility was unable to produce medication observation records (MOR) for six of six sampled residents. 163. That the Petitioner’s representative reviewed the Respondent’s records for six sampled residents, residents numbered one (1) through six (6), and requested documentation for unsampled residents. 164. That the Respondent could not produce medication observation records (MOR) for the facility residents, both sampled and unsampled. 165. That the Petitioner’s representative interviewed the Respondent’s staff who confirmed that no MORs were available for review. 166. The failure to maintain an accurate and up-to-date MOR is a direct threat to the health, safety, or security of facility residents. Said records must be depended upon by other staff to prevent over or under medication, on health care providers in reviewing the efficacy of prescribed medications, are necessary for the maintenance of accurate dosages of prescribed medications, and may be necessary to emergency personnel in health threatening situations. 167. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 168. That the Agency provided the Respondent with a mandatory correction date of January 13, 2005. 169. That during a re-visit survey conducted February 15, 2005, the Agency determined that the Respondent had corrected the deficiency. 170. That on May 25, 2005, the Agency conducted a biennial licensure survey of the Respondent facility. 171. That based upon the review of resident records and interview, the facility failed to maintain an up-to-date medication observation record (hereinafter “MOR”) for all residents who receive assistance with medications. Failure to properly document assistance with medications can threaten the residents' safety and well being. 172. That the Petitioner’s representative reviewed the MOR and medications for three residents. 173. That a review of three resident’s MOR’s revealed a total of thirty-five (35) omissions in which either the MOR did not have a caregiver signature reflecting who assisted with medication administration or no documentation of refusals by the residents. 174. That on the day of the survey, one omission occurred during the morning medication assistance pass. 175. That resident number three had been prescribed Paxil, 10 mg. one dosage daily. 176. That the MOR for resident number three did not contain an entry reflecting this prescription or the administration of the medication. 177. That the prescription orders for resident number two contained an order for Synthroid 125 mcg. The resident’s MOR listed this prescription at a dosage of 10 mg. 178. That the prescription orders for resident number two contained an order for Norvasc 10 mg. The resident’s MOR listed this prescription at a dosage of 20 mg. 179. That the petitioner’s representative reviewed the medications maintained for resident’s one and two. 25 180. That the medications for resident’s one and two contained prescription drug bottles filled in January, March, April, and May for each resident. 181. That of the four month supply of prescription medications maintained for these two residents, only one month of the total supply had been utilized. Three months of prescription medications were still in tact and had, presumably, not been administered to the residents. 182. That the Petitioner’s representative interviewed the respondent’s administrator regarding the medication supply. 183. The Respondent’s administrator alleged that medications were administered as prescribed and that excess medication may have resulted from duplicate medications obtained from the resident’s mental health provider. 184. That no records were observed that would reflect excess medications from a resident’s mental health provider or to otherwise account for this accumulation of unadministered and prescribed medications. 185. The failure to maintain an accurate and up-to-date MOR is a direct threat to the health, safety, or security of facility residents. Said records must be depended upon by other staff to prevent over or under medication, on health care providers in reviewing the efficacy of prescribed medications, are necessary for the maintenance of accurate dosages of prescribed medications, and may be necessary to emergency personnel in health threatening situations. 186. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class IT deficiency. 187. The Agency provided Respondent with a mandatory correction date of May 28, 2005. 188. That on July 7, 2005, the Agency conducted a follow-up to the biennial licensure survey of the Respondent facility. 189. That based upon the review of resident records and interview, the facility failed to maintain an up-to-date medication observation record (hereinafter “MOR”) for all residents who receive assistance with medications. Failure to properly document assistance with medications can threaten the residents’ safety and well being. 190. That a review of two resident’s medication observation records, residents number one and two, reflected completed MORs which indicated that all prescribed medications had been taken by the residents. The MORs contained no indication of a resident’s refusal of medications except for a single entry reflecting a refusal of resident number one on the date of the survey. 191. That the Petitioner’s representative reviewed the medications maintained for resident number one which revealed the following: a. That the resident was receiving four medications, three of which were scheduled for one per day. These were Risperdal 2mg., one each morning; Risperdal 4mg, one each evening; and Synthroid 8mg., one each day; b. That the resident’s medications were dispensed on June 13, 2005 and as of the day of survey there were twelve (12) pills left for each medication; c. That based upon the'prescribed dosage amount and frequency, there should have been only six (6) pills left for each medication; d. That the fourth medication was Reminyl, 8mg, one, two times per day; e. That this medication was also dispensed on June 13, 2005, and there were eighteen (18) pills left on the date of survey; f. That based upon the prescribed dosage amount and frequency; there should have been only twelve (12) doses left. 192. That resident number one was unable to communicate with the petitioner’s representative and was angry, combative, and on the day of survey had refused his morning medications. 193. That the medications prescribed would have an effect on the control of the resident’s moods and behavior and as such the failure of the resident to have received the medications as prescribed is a likely factor in the resident’s combative and angry mood and behavior. 194, That the Petitioner’s representative reviewed the medications maintained for resident number two which revealed the following: a. That the resident was receiving two medications which were scheduled for administration two times daily. These were Risperdal 4mg., two times daily, and Benadryl 25 mg., two times daily; b. That the resident’s medications were dispensed on June 13, 2005 and as of the day of survey there were eighteen (18) pills left for each medication; c. That based upon the prescribed dosage amount and frequency, there should have been only twelve (12) pills left for each medication; 195. That the Petitioner’s representative reviewed this information with the staff of the Respondent. 196. That the Respondent’s staff recounted three of the medications and concurred that the remaining medications exceeded the amount that should have been in stock had the medications been administered in accord with the prescribed dosage and frequency as reflected on the MORs. 197. The failure to maintain an accurate and up-to-date MOR is a direct threat to the health, safety, or security of facility residents. Said records must be depended upon by other staff to 28 prevent over or under medication, on health care providers in reviewing the efficacy of prescribed medications, such as medications intended to address behavioral issues, are necessary for the maintenance of accurate dosages of prescribed medications, and may be necessary to emergency personnel in health threatening situations. 198. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 199. That the Agency provided the Respondent with a mandatory correction date of July 10, . 2005. 200. That during a re-visit survey conducted August 10, 2005, the Agency determined that the Respondent had corrected the deficiency 201. That on October 8, 2005, the Agency conducted an appraisal survey of the Respondent. 202. That based upon the review of records and the review of medications the Respondent facility failed to maintain accurate up-to-date MORs for four of four sampled residents, and had no MORs for five additional unsampled residents, 203. That a review of facility records revealed that the Respondent facility had documented only four (4) individuals in residence on October 8, 2005. 204. That based on observations during a tour of the Respondent facility there were eight (8) individuals residing at the facility during the survey. 205. That the Petitioner’s representative interviewed resident number four (4) on October 8, 2005 who revealed that a ninth 9" individual was in residence at the Respondent’s facility, said individual sharing a room with resident number two (2). The subject individual was not at the Respondent facility at the time of the resident’s interview. 206. That the Petitioner’s representative reviewed the MORs for four sampled residents, residents one (1) through four (4), on October 8, 2005. 207. That none of the MORs for the residents reflected that any medications had been administered to the residents on October 7, 2005. 208. That the Petitioner’s representative interviewed the Respondent’s facility manager who offered no response or reason for the missing documentation. 209. That the Petitioner’s representative requested documentation for five unsampled residents, residents numbered five (5) through nine (9), resulted in no production by the Respondent of any MORs for these residents. 210. That the Petitioner’s representative observed medications in the Respondent facility purportedly being prescribed for these five (5) unsampled resident’s medications. 211. That there was no documentation produced by the Respondent regarding the assistance with these medications or who was being administered the medications. 212. The failure to maintain an accurate and up-to-date MOR is a direct threat to the health, safety, or security of facility residents. Said records must be depended upon by other staff to prevent over or under medication, on health care providers in reviewing the efficacy of prescribed medications, are necessary for the maintenance of accurate dosages of prescribed medications, and may be necessary to emergency personnel in health threatening situations. 213. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a twice repeated State Class II deficiency. 214, That the Agency provided the Respondent with a mandatory correction date of October 11, 2005. 30 215. That the same constitutes a repeat offense and as such, in part, justifies the imposition of an enhanced fine. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2005). COUNT X 216. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 217. That pursuant to Florida law, centrally stored medications must be kept in a locked cabinet, locked cart, or other locked storage receptacle, room, or area at all times.. Refrigerated medications shall be secured by being kept in a locked container within the refrigerator, by keeping the refrigerator locked, or by keeping the area in which [the] refrigerator is located locked. R. 58A-5.0185(6)(b) Fla. Admin. Code. 218. That on October 8, 2005, the Agency conducted an Appraisal Survey of Respondent. 219. That based upon observations the Respondent facility failed to keep centrally stored medications secured in a locked storage receptacle at all times in violation of law. 220. That the Petitioner’s representatives on October 8, 2005, while touring the Respondent facility, noted resident prescription medications stored in an unlocked cabinet in the designated medication room. 221. That this room is easily accessible from a hallway in the facility, and the room does not have a door. 222. That the following medications were observed to be in the unlocked cabinet: 1. Sampled resident number two (2) 31 Flomax 0.4mg. one every morning, 2. Sampled resident number four (4) Ambien (five tablets milligrams unknown) loose in a ziplock bag. 3. Resident number five (5) [no resident record available, no medication observation record available, resident resides in the facility, but had been listed as discharged in the Respondent’s the admission/discharge log. This resident was present in the facility on October 8, 2005] Risperdal 3 mg. one tablet twice a day. Prozac 20 mg. one every day. Haldol 5 mg. one by mouth every day. 4. Resident number six (6) [no resident record available, no medication observation record available, resident resides in the facility, but was not listed on the Respondent’s admission/discharge log. This resident was not observed in the facility October 8, 2005] Zantac 150 mg. one tablet by mouth twice a day. Leveteractam 500 mg. one tablet twice a day. Toprol 200 mg. one tablet by mouth every day. 5. Resident number eight (8) [no resident record available, no medication observation record available, resident resides in the facility, but was not listed on the Respondent’s admission/discharge log. This resident was present in the facility on October 8, 2005] Effexor 75mg. one tablet twice a day. Folic Acid 1 mg. one tablet everyday. Ferrous Sulfate 325 mg. one twice a day. Risperdal 0.5 mg. one by mouth at bedtime 6. Resident number ten (10) [no resident record available, no medication observation record available. This resident was not observed in the facility on October 8, 2005. The manager stated the resident expired in March 2005] Norvasc 5 mg. one tablet every day. That the failure to maintain medications in a locked storage area as mandated by law creates the risk for medications to be taken by someone other than the resident for whom they were ordered and also presents a potential for tampering. Said risk includes 32 intentional action and unintentional action including, but not limited to, the risk of a resident self administering medications in amounts of or types of medication which could be seriously detrimental to the resident’s health and well being. 224. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 225. That the Agency provided Respondent with a mandatory correction date of October 11, 2005. 226. That the same constitutes grounds for a Class II deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(1)(b), Fla. Stat. (2005). COUNT XI 227. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth 228. That pursuant to Florida law, no prescription drug shall be kept by the facility unless it is properly labeled and dispensed in accordance with Chapters 465 and 499, F.S. R. 58A- 5.0185(7)(a) Fla. Admin. Code. 229. That on January 10, 2005, the Agency conducted a complaint investigation of the Respondent. 230. That based upon medication review on January 10, 2005 for three sampled residents, the Respondent facility failed to ensure that all medications are properly labeled and dispensed. 231. That the Petitioner’s representative reviewed the Respondent’s facility records and 33 medications on January 10, 2003. 232. That a review of resident number two’s (2) medication revealed two medication bottles with no pharmacy prescription labels. 233. That the medication bottles were labeled by hand with a magic marker, Phenergan nausea one a day and Dramamine for dizziness only if needed. 234, That five other medications for this resident had no specific directions for their use (A thru Z vitamins-no directions; Equate tussin 8 ounce bottle - no directions for use; Acetaminophen 500 mg. - no directions for use; Imodium AD box - no directions for use; Aspirin 325 mg. with directions handwritten on bottle- one a day) and these medications do not match those on the Resident’s Health Assessment (1823). 235. That no medication observation records and no physician's orders were available for review. 236. That the Petitioner’s representative interviewed the Respondent’s staff who indicated that this resident does not always take all medications available and confirmed documentation and MORs are not available. 237. That these deficiencies place the resident at risk for receiving inappropriate medication and could cause life threatening complications 238. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 239. That the Agency provided the Respondent with a mandatory correction date of February 13, 2005. 240. That during a re-visit survey conducted February 15, 2005, the Agency determined that 34 the Respondent had corrected the deficiency. 241. That on October 8, 2005, the Agency conducted an Appraisal Survey of the Respondent. 242, That based upon observations and facility staff interview, the facility failed to ensure that medications were kept by the Respondent facility with proper labels and dispensing practice in violation of law. 243. That the Petitioner’s representative reviewed the Respondent's facility records on October 8, 2005. 244. That the Petitioner’s representative observed in the Respondent’s designated medication room on October 8, 2005 revealed one medication for resident number four (4) in an unlocked cabinet. 245. That the medication consisted of five Ambien tablets. Ambien was written across the tablet, and the medication was stored in a zip lock bag with the resident's name written on the zip lock bag with a marker. 246. That the Petitioner’s representative interviewed the Respondent's facility manager, who was also the designated medication person for that day, who indicated that the Ambien belonged to resident number four (4), but she was unaware of how the medication got there. She also stated that they were 10 mg. tablets. 247. That this puts the resident at risk for receiving inappropriate medication and could potentially cause life threatening complications. 248. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a repeat State Class II deficiency. 249. That the Agency provided the Respondent with a mandatory correction date of October 35 11, 2005. 250. That the same constitutes a repeat offense and as such, in part, justifies the imposition of an enhanced fine. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla, Stat. (2005). COUNT XI 251. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 252. That pursuant to Florida law, any assisted living facility in which the Agency has documented a class I or class If deficiency or uncorrected class III deficiencies regarding medicinal drugs or over-the-counter preparations, including their storage, use, delivery, or administration...during a biennial survey or a monitoring visit or an investigation in response to a complaint, shall, in addition to or as an alternative to any penalties..., be required to employ the consultant services of a licensed pharmacist, a licensed registered nurse... The consultant shall, at a minimum, provide onsite quarterly consultation until the inspection team from the Agency determines that such consultation services are no longer required. Section 400.442(1) Fla, Stat. (2005). Ifa Class I, Class IJ, or uncorrected Class IIL deficiency directly relating to facility medication practices as established in Rule 58A-5.0185, F.A.C., is documented by Agency personnel pursuant to an inspection of the facility, the Agency shall notify the facility in writing that the facility must employ, on staff or by contract, the services of a pharmacist licensed pursuant to 465.0125, FS ., or a registered nurse, as determined by the Agency. R. 58A- 5.033(4)(a)(3) Fla. Admin. Code. 36 253. That on July 7, 2005, the Agency conducted a follow-up survey of the Respondent. 254, That based upon the review of Respondent’s records and interview, the Respondent failed to employ the services of a licensed consultant pharmacist or registered nurse after having been so required, the same being in violation of law. 255. That the Agency conducted a biennial survey of the Respondent on May 25, 2005. 256. That as a result of said survey, the Agency cited the Respondent with a Class II deficiency regarding the facility's medication practices. 257. That the Agency notified the Respondent in writing via letter dated June 1, 2005 of the Agency imposed requirement, pursuant to law, that the Respondent retain the services of a consultant pharmacist or registered nurse. 258. That a review of facility records on July 7, 2005 reflected no records or documentation that the respondent had contracted with a consultant pharmacist or registered nurse to assist in correcting errors in the process of assisting residents with their medications. 259. That the Petitioner’s representative interviewed the Respondents staff member on July 7, 2005, who indicated that neither the staff member nor the Respondent’s administrator had read the letter from the Agency imposing the requirement of the respondent’s employment ofa consultant and they had not complied with the requirement as directed. 260. That the failure of the Respondent to comply with Agency imposed requirements regarding a professional to assist with medication assistance places the residents of the facility at continued risk of errors in the monitoring and administration of medications. 261. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 37 262. That the Agency provided the Respondent with a mandatory correction date of August 7, 2005. 263. That during a re-visit survey conducted August 10, 2005, the Agency determined that the Respondent had corrected the deficiency 264. That on October 8, 2005, the Agency conducted an Appraisal Survey of the Respondent. 265. That based upon the review of Respondent’s records and interview with the Respondent’s nurse consultant on October 8, 2005, the facility failed to provide a licensed consultant pharmacist or nurse to consult on medications for all of the residents at the facility in violation of law. 266. That the Petitioner’s representative reviewed the Respondent’s facility records on October 8, 2005, 267. That a review of resident records revealed that only four (4) of nine (9) residents at the facility had medication observation records. 268. That a review of the Respondent’s consultant agreement with a nurse consultant reflected that the consultation services covered only the four (4) residents who were listed on the Respondent’s admission/discharge log, 269. That the Petitioner’s representative interviewed the respondent’s nurse consultant on October 8, 2005 who indicated the following: a. That the Respondent’s administrator had provided records for only four (4) residents; b. That her visits included the writing of the medication observation records for only four (4) residents; c. That she was unaware of the other five (5) residents at the facility until October 8, 38 2005; d. That the Respondent’s administrator was at the facility during her visits and had advised her that only four residents were at the facility. 270. That this failure of the Respondent to inform the nurse consultant of and receive consultant services for the five (5) other residents at the facility places these residents at risk for inappropriate assistance with medications, and did not enable the nurse consultant to completely and accurately assist the facility for all the residents and their needs. 271. That the nurse consultant terminated her affiliation with the facility on October 8, 2005. 272, That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a repeat State Class II deficiency. 273. That the Agency provided the Respondent with a mandatory correction date of October 11, 2005. 274, That the same constitutes a repeat offense and as such, in part, justifies the imposition of an enhanced fine. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2005). Respectfully submitted this / Fay of November, 2005. Thonfas A Fla. Barf No. 566365 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 39 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308; T elephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE IHEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7003 1010 0002 4667 1064 on November /‘t, 2005 to Catherine G. Amold, Reg. Agent/Owner, 11429 Portside Drive, Jacksonville, FL 32225 Thende’V Walsh I Senior Attorney Copies furnished to: Catherine G. Arnold Thomas J. Walsh, II, Esq. Registered Agent/Owner Agency for Health Care Admin. 11429 Portside Drive 525 Mirror Lake Drive, 330G Jacksonville, FL 32225 St. Petersburg, Florida 33701 (U.S. Certified Mail) (Interoffice) 40 PAYMENT FORM Agency for Health Care Administration Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. in the amount of $ which represents payment of the Administrative Fine imposed by AHCA. Arnold’s Angels 2005009684 Facility Name AHCA No. SENDER: COMPLETE Zui SECTION = Complete items 1, 2," .. + 3, Also complete item 4 if Restricted Delivery ts destred, ® Print your name and address on the reverse so that we can return the card to you. ™ Attach this card to the back of the maliplece, * or on the front if space permits. 1, Article Addressed to: Catherine, o Arreld Q rot |coad Rep oc ae orc we eraone\le Flor'da. ‘COMPLETE THIS SECTIOMM@ON DELIVERY D. Is delivery address different from item 1? 1 Yes If YES, enter delivery address below: © No [| 3. Sey C O Certified = fegistered 1 Insured Mail q Retum Receipt for Merchandise Oc.o.p. 3242.25 4, Restricted Delivery? (Extra Fea) C1 Yes 2. Article Number 1 (Mansfer tom & 7003 1010 0002 4647 1ob4 AO00500 % 24 PS Form 3811, February 2004 Domestic Return Recelpt 102595-02-M-154¢ Ahead Ce

Docket for Case No: 06-000675